What happened
On November 30, 2023, at approximately 10:30 UTC, a Neiva EMB-201A, registration PT-UED, was performing a solo flight for an Agricultural Pilot Course at the Palmeira das Missões Aerodrome (SSPL) in Rio Grande do Sul, Brazil. The flight was part of the practical instruction program for a flight school (CIAC Ícaro Ltda).
During the landing phase on runway 05, the pilot attempted a three-point landing. The initial touchdown was described as heavy and at excessive speed, causing the aircraft to bounce back into the air. On the subsequent landing attempt, the aircraft touched down on its left main gear. The pilot was unable to maintain directional control, causing the aircraft to veer off the right side of the runway. The aircraft traveled approximately 3/0 meters across the grass area before striking an embankment. The aircraft sustained substantial damage, though the pilot remained uninjured.
The investigation
CENIPA's investigation focused on the flight techniques used and the organizational procedures of the flight school. Investigators found that while the school's Standard Operating Procedures (SOP) prescribed a landing technique where the main gear touches first followed by the tailwheel, the actual instruction provided to students utilized a three-point landing technique. This discrepancy was reportedly due to a consensus among instructors that the three-point method was easier to execute and less risky.
Furthermore, the investigation examined the maintenance and regulatory status of the aircraft. The PT-UED was found to have a valid airworthiness certificate, and all maintenance logs for the airframe, engine, and propeller were up to date. The pilot held a valid commercial pilot license and medical certificate, and the weather conditions at the time of the accident were well within operational minimums.
Findings
- Inconsistent landing techniques: The flight school was teaching a landing method that contradicted its own written SOPs.
- Pilot error: The pilot's judgment regarding the timing of the touchdown was incorrect, and the aircraft approached the runway with excessive energy and an unstable flight path.
- Organizational culture: A lack of adherence to established procedures and a lack of clear instructional material regarding error correction contributed to the accident.
- Management oversight: There was a failure in managerial supervision to ensure that instruction remained aligned with the approved SOPs.